The use of an opioid risk tool may help you identify patients who are at high risk of ... There are a number of opioid r
OPIOID PRESCRIBING DECISION AID Opioids are an important medicine for the management of pain. However, opioid misuse is a significant risk for anyone using opioids. Balancing the need for pain relief with harm minimisation can be challenging. Being overly suspicious of requests for opioids may leave people feeling stigmatised and prevent people getting access to medicines that may improve their quality of life. The Tasmanian Department of Health has developed an 8-step checklist that can be used at any point during the management of patients on opioids, such as initiation, or when making decisions to increase dose, reduce therapy or manage patients showing signs of misuse or side effects from opioids.1
8 Cs
of prescribing opioids
Clinical indication
Are opioids suitable for this indication? Has the patient been treated with appropriate non-opioid analgesia at the correct dose prior to the decision to use opioids?
Clinical risks
Are there considerations regarding comorbidities or interaction with other medicines?
Consider signs of misuse or abuse
Is the patient displaying any signs of dependence, misuse or abuse? (Table 1)A
Control dose
Use the lowest effective dose. Avoid exceeding accepted maximum doses.B
Contract
Consider the use of an opioid contract signed by patient and prescriber. This should include treatment goals and agreement to discontinue if goals are not met.C
Contact PBS
Apply for authority as per State or Territory legislation.
Contain prescription
Single prescriber and single pharmacy prescription is recommended to prevent doctor shopping.
Consensus between parties
Regarding treatment, for example: outcomes such as function, review frequency, other treatment strategies and discontinuation plan.
A
The use of an opioid risk tool may help you identify patients who are at high risk of misuse. There are a number of opioid risk tools. The one commonly recommended in Australia is the Opioid Risk Tool
Maximum doses2: Morphine oral modified release 100 mg daily; Oxycodone oral modified release 80 mg daily; burepnorphine transdermal patch 20 micrograms/hr
B C
An Opioid contract such as the one recommended by the Agency for Clinical Innovation (NSW) may be a useful template to use with people currently taking opioids or requesting them for the first time
TABLE 1
Behaviours that may indicate misuse
Highly predictive behaviours
Less predictive behaviours
Selling prescription medicines
Abrupt requests for dose escalation
Injecting oral formulations
Hoarding of medicines during periods of reduced symptoms
Concurrent abuse of alcohol and/or illicit substances
Requesting specific medicines
Multiple unsanctioned dose escalations
Unsanctioned dose escalation
Multiple claims that prescriptions have been lost
Unapproved use of medicine to treat other symptoms
Repeated resistance to change in therapy despite evidence of adverse effects from treatment
The Department of Health and Human Services. Protocol for prescribing opioids in Tasmania. 2011. http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0004/77701/ Protocol_for_prescribing_opioids_in_Tasmania.pdf (accessed 4 March 2015).
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2. Expert Group for Analgesics. Therapeutic Guidelines: Analgesic version 6. Melbourne: Therapeutic Guidelines Ltd, 2012.
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